Complaint Investigation Report

Residents sustained falls due to lack of supervision - UNSUBSTANTIATED

It was reported that residents are falling because there is only one staff providing care and supervision in the memory care unit.

LPA reviewed records of falls that were reported for the months of September through November 2023. One memory care resident fell on 09/18/23, was transported to hospital for assessment. There were no falls reported for the month of October 2023 and thus far none for the month of November 2023 in the memory care unit.

LPA reviewed memory care staffing schedules for the months of September and October 2023. The facility has four shifts in the memory care unit. All shifts had one Med Tech and one to two PCA’s. In addition, the facility has recently increased their staffing in the memory care unit.

During the month of September 2023 PCA’s called out or did not show up for their shifts on the following days during the 6:00 am – 2:00 pm shift exclusively: five days no show. 9two days PCA – Personal. One day PCA – Sick. On 9/17 two PCAs did not show up for their shifts which resulted in one PCA working back-to-back shifts to cover.

3 of 5 staff stated 2 residents have fallen, one fall resulted in a contusion. 1 of 5 staff stated that one resident fell from time to time but was not injured. 1 of 5 staff stated they did not know if there had been any falls.

Expressions Director stated I have enough staff when they don’t call in with me back here also.

Executive Director stated there are two care staff, the med tech and the director on duty to provide care.

It was determined that the facility has not had an increase in falls due to insufficient staffing and lack of supervision. This allegation is unsubstantiated.